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� ,Y. r .-,!�-r yi �i'_rr�q L•?,�rj��t"��.,:�.' 8a �w��h� Y�.e�L�'. 'S' f .r,rYf�-,.5_ a,.v e - ��, �c:, � ."'" '��" r�rpyry n. "'"'� E -a -L fr -r• , `k., 1601 E. HAZE T ON AVE., STOCKTON, CA l Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin �i Local Health District. Job Address Y uz-'w Cit r�► Lot Size op _PM -- Owner's Name * +�r Address�Z!_ C �CLi C? L��1Cltc C� Phone �5 }�I, r , t ContractoD4U 11� IU-L' I Address 03 1',d t License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C] PUMP INSTALLATION , SYSTEM REPAIR © OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.`LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS FjINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom C] Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications f{ f'1 Public f-] Other Cl Delta Depth of Grout Seal Type of Grout __+ z I I Irrigation _..Approx. Depth I I Eastern !Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. 1 State Work Done Well Destruction C] Well Diameter Sealing Material [top 501 f ^ Depth � Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence— Commercial_ Other b Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number F( SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t rules and regulations of the San Joaquin Local Health DFstrict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not ' employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or,sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subjet to workman's compensa- tion laws of California." �fouire The applicant st callins tions. Complete drawing on rave se side. Signed X Title: <��,� � ✓ Date: Z=D F. DEPARTMENT USE ONLY i Application Accepte by Date Area f Pit or Grout Inspection by Date Final Inspection by Date 2 'Z I Additional Comments: r ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 n Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . i INFO AMOUNT DUE rAMOUNT REMITTED CK It CASH RECEIVED BY DATE PERMITNO. ♦.EH 13-24(REV.tiK51 r1�-.� l � - f 1 Eli 14-29